Nursing Case Study: Pneumonia History of Present Illness (HP…
Nursing Case Study: Pneumonia History of Present Illness (HPI): Mrs. H.A., age 70, is admitted with acute community-acquired pneumonia. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. Upon assessment, the patient has slowness in filling of veins of the hands and feet, and poor oral intake. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and an absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he cannot raise any sputum. ELECTRONIC HEALTH RECORD NAME H. S. AGE 70 ALLERGIES PCN Isolation Precautions None DOB 10/14/1952 MRN 123456 CODE STATUS Full code LABS WBC: 11.2 Hgb/Hct: 10/30 Plt: 350 DXs EKG Chest X-ray:RLL consolidation& small pleuraleffusion Healthcare Provider Orders Diet Regular diet as tolerated IV Fluid ½NS at 75 ml/hr Activity Ambulate as tolerated Medications Oxygen at 2L via nasal cannula & titrate to keep O2 sat> 93%acetaminophen (Tylenol) 650 mg PO q4h prn temp > 100.5 Radiology Chest x-ray (CXR) in AM Labs CBC in AM VITAL SIGNS: Temp Pulse RR BP SaO2 Pain Today at 0800 101.5°F 101 28 90/50 88% on room air 3/10 prn cough Identify Mrs. H.A.’s actual problems vs potential problems: